Redesigning a System of Care to Promote QI

Process Mapping or Flow Charting is one of the most powerful tools for process improvement. The map is optimally created by a team to assure that there is agreement in how the process currently works. Variation in how work is performed is a frequently encountered contributor to low performance.

Now that the Quality Improvement Team has worked hard to redesign systems improve performance, it is time to focus on assuring that those improvements "stick"and to evaluate opportunities to spread improvement to other parts of your organization. It is important that improvement leaders take the time to reflect and plan the next steps forward. The most critical question must be: did we accomplish our aim? If not, it is prudent to reconsider how to move forward. Three scenarios are commonly seen in the field:

Improvement efforts were unsuccessful due to lack of resources or focus. This is commonly the situation when organizational improvement projects have been derailed by competing priorities or significant changes in leadership. If the situations that impacted your progress have resolved, it is reasonable to re-calibrate and start the QIP again.

Unanticipated challenges arose during your work that will prevent you from achieving your aim. Resource cuts, changing organizational priorities or unanticipated changes in demand for services are examples of situations that might not be readily remediated. In these circumstances, it is often best to regroup and focus once again on what is most important. The xxxx module describes how to consider options for QIPs and may be relevant to help teams change gears.

The aim was not achieved within our time frame but we are progressing. In these situations, often times it is best to recalibrate the time frame and continue the work.

The key point is that if you did not achieve what you set out to do, it is better to continue that journey and only then move on to activities to sustain and spread. Said another way, it is important to spread success, not a work in progress. The rest of this module will deal with considerations in redesigning your systems to sustain and spread improvements. The assumption now is that you have been successful in improving systems of care and that those improvements are worthy of sustaining and spreading.

During the improvement journey, you have experienced the fact that complex systems tend to evolve or revert back to previous iterations organically. So the task to sustain the gains is really this: how can we stabilize the systems that result in excellent performance so that it is resistant to these typical dynamics?

For many, it has been helpful to envision a near 100% turnover in staff. Would the care for diabetic patients remain excellent if Mary the MA was not there to go that extra mile every day and call patients who had not been in for care? Or if Dr. Jones did not encourage his provider team to aggressively manage blood pressure for their patients? The reason this visualization is helpful is because it helps us to avoid a large pitfall in improvement work: person-dependent systems. This concept is critical and needs to be considered all during the planning for sustaining, and later spreading, improvement.

Creating a Sustainability Plan

It is useful to be very clear about those processes and systems you want to sustain. We remember that every system is perfectly designed to get the result it achieves, so what are you doing differently now to result in improved performance? This is where those PDSA summaries come in handy! Teams will often look back over minutes or have conversations about those changes that worked. Once the team is clear about what needs to be sustained, the work can begin. Typically the work will involve three distinct categories:

Leadership & Finance

Operations: Policies and procedures, information technology

Staff

Leadership & Finance

Leadership must understand what has changed and the benefits of those changes. Most often, the recognition will come at the end of the QIP when progress is measured against the aim. But at times, leaders may view quality improvement as just a project not an ongoing concern. So it is important to have the conversation and assure that leaders are committed to sustaining (perhaps also spreading) these improvements. In particular, any costs incurred due to the changes must be covered. Examples of changes often linked to improvements with financial impact include staffing changes, hours of operation, facility utilization and supplies. Many organizations have found that successful quality improvement opens other doors for revenue – the so called business case for quality improvement. Organizations find that expense reductions and revenue enhancement can result from improvements. A few examples include:Expense reductions:

Additional patients seen/fte due to more efficient work flows and team based care

Pay-for-performance money based on improved quality outcomes from payers

Additional grant opportunities based on quality systems and ability to appropriately measure and improve performance.

Once leaders are convinced that the improvements make sense financially and will further the organizational mission, it is important that they communicate that the improved systems are here to stay. One popular way leaders have communicated this to staff is by explaining that this is the new way of doing business. Accompanied by messages about how the improvements will benefit patients, staff and the organization as a whole, this commitment to the improvements from leadership is an essential step in sustaining the gains.

Operations

Assuring that changes are completely incorporated into how the daily work is accomplished is critical to sustaining change. Even though the changes were tested during the redesign phase, it is important that managers observe the impact of these changes on a daily basis. It is impossible to think about every possibility that might come up, so being vigilant is helpful to handle unexpected challenges early on. Operations work will typically look at the impact of the changes on staff work flow, gaps in training created by the change, the need to update operating procedures as well as the impact to staff morale and the effect the changes have on the patient experience.

Staff Work Flows

The redesigned system should function smoothly and not be a strain for staff to accomplish. Systems with redundancies or inefficiencies will not survive as staff will naturally develop "work arounds. " Teams that have used TPS/Lean thinking in their redesign are less likely to have challenges. It is better to tweak systems early if problems do arise. In particular, managers should look at the "handoffs" – a word used to describe a transition from one person or role to another. In ambulatory care, handoffs are common: front desk, MA, provider, MA, lab, front desk and perhaps outreach. Information and responsibility must flow smoothly for optimal patient benefit.

Training

Many great redesigns have been sabotaged by lack of attention to training! No one enjoys being put in a position where they are asked to do something they are not comfortable doing. Adequate training and or mentoring should be provided to staff who may have adopted new roles or new tasks. Computer skills, using new parts of the HER, comfort in assessing tobacco use or progress on a self management goal are all examples of tasks that may be unfamiliar to staff. Staff that feel competent and comfortable with their role within the care team will contribute to the success of the redesigned systems.

Operating Procedures

Documentation of standard operating procedures is not always completed in the midst of a busy office. The benefits are to assist with standardization if several individuals perform that task, to document steps to assist staff to learn a new way to do the work as well as to help orient new staff. One strategy that works well is to incorporate the process map of the redesigned system into the procedure. It is a helpful visual display and help give context to the work. In conjunction with updating operating procedures, it may be appropriate to update job descriptions, hiring criteria, evaluation matrices and orientation manuals. This written documentation will also facilitate spread to other teams, sites or systems of care.

Staff Morale

Change is always challenging but since redesigned systems typically are improvements, these changes are easier than most. It is important to reinforce why the change is essential and to support staff that may have difficulty. It is also important to communicate to staff the data that illustrates the benefit of the change – improved A1c outcomes for patients as an example. Emphasizing that all team members’ contributions are important to making the redesigned system work is also helpful.

Patient Experience

It is well documented that when considering satisfaction, patients do not think as much about quality as they do about how they are treated and how long they wait. Therefore patients will be more likely to notice how the office "feels" and the time it takes from time in to time out. Communicating with patients the rationale for the change, especially if there are bumps initially is reassuring to patients. Ultimately, patients appreciate that the staff are working to improve their health and will more readily accept changes if appropriately informed. It is also helpful to get feedback from patients about any other opportunities to improve from the patient perspective.

We have discussed some critical aspects of involving and communicating with staff in the operations section. Supporting staff with training, written documentation to ensure clear expectations and the rationale and benefits of the change are important. In addition, we need to remember that change is more of a social process – people change at different rates and for some, change is harder than for others. Managers who will be in a position of managing change may benefit from additional reading.

In quality improvement jargon, spread means taking improvements and applying them to different care systems. Spread can involve sharing improvements with other teams within the same site, with teams in other sites and can also involve translation of the process of the approach to improvement to other topics or conditions. Throughout the toolkit, we have emphasized that there are core methodologies to improvement work. Teams with experience in one topic are often able to use a similar approach to others. Spread from one team to another and one site to another requires a bit more planning and thought. We will concentrate on considerations for spreading improved and redesigned systems to other health care teams in this module.

Staff Morale

As with most major changes, you must start with leadership. Typically, leaders will be convinced during the evaluation of whether to sustain a change [link back to prior section] if the redesigned system would benefit other care teams or sites. Often, there are economies in standardization. Constraints and the specifics of other populations served will need to be evaluated prior to the decision to spread.

Preparing the Spread Team

Teams that have successfully redesigned a system has resulted in improvements are typically excited and ready to share. If change were easy, the improvement team could just share what was different, spread teams would adopt it immediately and all would be well. But we know that this strategy is flawed although many of us have experienced it. The rationale for a different approach comes from an understanding of human nature and the response to change. The process of spread is really social. One group of individuals is trying to convince another to change the way they do things. One way to think about this process is that teams who will accept change must be ready, willing and able to change.

Ready

Readiness to accept a change is necessary. Spread teams must agree on some level that the redesigned system will be an improvement. Remember that they are typically not involved day-to -day in the improvement process and may be wary of any changes, fearing the worst. It is helpful for member of the improvement team to explain the rationale for the changes, the process of testing and the success that has been gained. Describing a few failures is helpful to humanize the process and is reassuring to those who are trying to assess the process that led to the redesigned systems. Spread teams will be more ready to change if they see a pathway that is reasonable. Data that was used to monitor the journey as well as PDSA logs are helpful adjuncts to the discussion.

Willing

Once a spread team hears the rationale for the change, they need to assimilate that information within their own context. It cannot be assumed that changes that work for one team will work for another without modification. Spread teams often ask if this is really starting over with an improvement process and it is not. But teams who will be changing need to embrace the change. Sometimes that means some tweaks to make it fit the particular circumstances. Sometimes it means that the spread team needs to fingerprint those changes as a way of making them their own.

Able

Once a spread team embraces the change as valuable and worthwhile, they need the time, authority and resources to make the change. Leadership is instrumental in ensuring that the spread team has what it needs to spread redesigned systems.

How does the Spread Happen?As with any change process, it is important to have a plan. The Spread Plan will outline what will happen, who will be involved as well as the time frame. Most often, the spread is monitored with the same metrics as used by the improvement team. A plan is reassuring to staff and facilitates the transition effectively.

Spread Plan Components:

List changes to be spread

Evaluate new system against current system: process mapping helpful and identify key differences. These will be the areas that the spread team will focus on to make the changes.

Discuss potential impacts or challenges that adopting the redesigned system will have and develop a plan to manage those impacts

Create an action plan to make the changes including how you will capture information to monitor. Identify those areas you can just change and those areas where it might be more prudent to test changes using PDSA methodology. Consider using PDSAs when there are associated impacts due to differences between the improvement team site and the spread team site.

Once the spread team is satisfied that the redesign has been adopted with or without modifications, follow the sustain steps. This will assure that the redesigned system will "stick" at the spread site.

How quickly spread can happen depends a lot on the change, anticipated impacts of the change on the spread team and the culture of the organization.

Example:

Suppose an improvement team redesigns an improved system of care that works to improve prenatal first trimester access. If the redesigned system is to be spread to other care teams within the same facility that serve the same population, spread might happen fairly quickly. Staff from other teams could be asked to take all of the changes including updated policies and procedures and HR practices and adopt them. If styles among provider teams are substantially different, more time might be needed to navigate these changes. If these changes were to be spread to another site with perhaps a different patient mix, more thought and planning might be necessary. A common example is one where the improvement team from the site that developed the improvement serves a different demographic group then the spread site. The spread site might need to tweak suggested improvements to allow for cultural competency or health literacy issues to best serve the population. In this case, Executive leadership, the improvement team and the spread site come to a consensus about what makes sense to implement and what areas might benefit from some additional PDSAs.

The plan will also lay out which of the supporting materials such as procedures, job descriptions etc discussed in the sustain section can be adopted and which might need modifications. If the site for the spread team is significantly different than that of the improvement team, the process of spread may resemble the improvement process somewhat where the spread team will test parts of the redesigned system with PDSAs to assure a good fit. The spread process is almost always less time consuming than the original improvement process but rushing it is not advised. Teams that adopt a redesigned process often become interested in improving other systems. Spread teams can become quality improvement teams as the cycle of continuous improvement perpetuates.